Snoring Survey | Snoring Laser Care

General Information

Name*

First Last

Date of Birth DD/MM/YYYY*

Email*

Address*

Street Address Address Line 2 City State / Province / Region

Medicare Number and your reference number*

Which Practice Location are your closest to?*

Snoring Laser Care treatment will ultimately require a series of appointments at our Mackay clinic. Some preliminary visits, such as consultation can be booked at our Moranbah clinic.

Epworth Sleepiness Scale

Do you snore?

Please tick how likely you are to doze off or fall asleep in the following situations:

Sitting and Reading

Would never doze
Slight chance of dozing
Moderate chance of dozing
High chance of dozing

Watching television

Would never doze
Slight chance of dozing
Moderate chance of dozing
High chance of dozing

Sitting inactive in a public place

Would never doze
Slight chance of dozing
Moderate chance of dozing
High chance of dozing

Passenger in a car

Would never doze
Slight chance of dozing
Moderate chance of dozing
High chance of dozing

Lying down to rest in afternoon

Would never doze
Slight chance of dozing
Moderate chance of dozing
High chance of dozing

Sitting & Talking to someone

Would never doze
Slight chance of dozing
Moderate chance of dozing
High chance of dozing

Sitting quietly after lunch without alcohol

Would never doze
Slight chance of dozing
Moderate chance of dozing
High chance of dozing

Driving a car, while stopped for a few minutes in traffic

Would never doze
Slight chance of dozing
Moderate chance of dozing
High chance of dozing

Questions

Snoring

Yes
No

Do you Snore Loudly (loud enough to be heard through closed doors or your bed-partner elbows you for snoring at night)?

Tired

Yes
No

Do you often feel Tired, Fatigued, or Sleepy during the daytime (such as falling asleep during driving or talking to someone)?

Observed

Yes
No

Has anyone Observed you Stop Breathing or Choking/Gasping during your sleep?

Pressure

Yes
No

Do you have or are being treated for High Blood Pressure?

Please enter your height (in cms) and weight (in kgs)*

Body Mass Index more than 32 kg/m2?

Yes
No

Age older than 50?

Yes
No

Neck size large ? (Measured around Adams apple)

Yes
No

For male, is your shirt collar 17 inches / 43cm or larger? For female, is your shirt collar 16 inches / 41cm or larger?

Smoker?

Yes
No

Alcohol consumption

Yes
No

For males, more than drink more than 20 drinks per week? For females, more than 10 drinks per week?

Gender

Male
Female

What has prompted you to seek help?*

I am aware I have a snoring problem
My partner has advised I have a snoring problem
My health
Other

Are you currently using any device or appliance?*

To proceed any further, understand you will need to complete a sleep study and a series of xrays and scans.*

I have sleep study report less than 12 months old
Supply me with information to get sleep study done
Supply me with referral to get scans & xrays done
Neither - I will ask my GP for same

Our method is to fully investigate your problem. Steps will need to be completed prior and after consultation before any treatment can be done. 1. Sleep study report (less than 12 mths old) 2. Xrays and 3 D scan of airways Costs will apply

Best contact phone number*

Our Snoring Laser Care Consultant will attempt to call you to discuss your result within a reasonable time frame. Also check your emails for further information. Response times vary, but you can always call if you would like. 49425111 ext 1 - available Monday to Wednesday.

Step 1 of 3

Step 1

General Information

Epworth Sleepiness Scale

Questions

WOULD YOU LIKE TO

Take a Complimentary Snoring Test